Hi Dr. Hall,
I really hope you can help me.
I am not sure if my issue is related to my lips, teeth or jaw but I absolutely can’t stand my smile. It feels very forced to be able to show my upper teeth. When my mouth is in repose it is just empty space and you cannot see my teeth (especially my upper) and it makes me extremely self-conscious.
I also have jaw pain and wear a night guard and when I wear it my mouth feels more comfortable and I feel like it supports my lips better. It also gives an impression of upper tooth show that I would very much like. I also find I have difficult pronouncing certain words especially when it’s cold, almost as if my jaw tighten and I can’t open it properly to speak. P and T words are especially uncomfortable.

Are my only options veneers? Do I even have any options?

It’s very frustrating for me. I can attach pictures as well if need be.
– Laura from Toronto

Laura,
You’re going to need to be very careful how your proceed here, and if a dentist has told you that porcelain veneers will solve your problem, I would find another dentist. While that could help with your appearance, it could exacerbate your other problems—the jaw pain and trouble with pronunciation.

It sounds to me like you’ve worn your teeth down, making you overclosed. This could cause TMJ disorder, which would be characterized by jaw pain and possible tightness in your jaw. The fact that you feel better wearing a nightguard lends credence to that diagnosis, but you’ll need an examination by a dentist trained in TMJ therapy to confirm that.

The needed treatment, unfortunately, is likely to be extensive—probably a full-mouth reconstruction.

The problem is finding a dentist you can trust to do this. This is way beyond the capability of your average family dentist. I would look for a dentist with advanced training from one of three institutes:

The Pankey Institute in Florida

The Dawson Academy, also in Florida

The Las Vegas Institute for Advanced Dental Studies

Good luck.
Dr. Hall

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About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

I am not sure if my issue is related to my lips, teeth, or jaw, but I absolutely can’t stand my smile. It feels very forced to be able to show my upper teeth. When my mouth is in repose it is just empty space and you cannot see my teeth (especially my upper) and it makes me extremely self-conscious.

I also have jaw pain and wear a night guard and when I wear it my mouth feels more comfortable and I feel like it supports my lips better. It also gives an impression of upper tooth show that I would very much like. I also find I have difficulty pronouncing certain words especially when it’s cold, almost as if my jaw tightens and I can’t open it properly to speak. P and T words are especially uncomfortable.

Are my only options veneers? Do I even have any options?

It’s very frustrating for me. I can attach pictures as well if need be.
– Laura from Ontario

Laura,
I’m glad you’re emailing me now, before going to a dentist to have this fixed. It’s painful to have to write back to people after a problem like yours and the dentist messed up their mouth.

This is a very difficult problem and you need to be very careful in picking a dentist to treat this for you. While I can’t tell for sure just with your description, it sounds like you may have a collapsed bite plus some other complicating TMJ issues (TMJ disorder). Veneers wouldn’t be the answer, at least not as a sole treatment. Opening your bite with crowns could solve your problem, but it would need to be done methodically by a dentist with experience in full-mouth reconstruction.

The proper way to open a bite is to do it reversibly first, with some type of provisional restoration. When that provisional is successful, then permanent restorations should be made that duplicate what was done provisionally. By successful I mean that you are out of pain, are happy with your appearance, show your upper teeth normally, and have no speech difficulties. That’s a tall order, but a dentist with adequate training should be able to do this.

It’s a small minority of dentists who have the training needed to address this type of situation. There are several training institutes in the United States that train dentists in this level of complex restorative dentistry. Those would be the L.D. Pankey Institute and the Dawson Academy in Florida, and the Las Vegas Institute for Advanced Dental Studies in Nevada. There are others, but these are the best known. I don’t believe there are any such institutes in Canada.

To help cement this idea of being careful in picking a dentist to do this, you may want to visit other blog posts I wrote for patients where the dentist opened their bite and caused more problems than they started with.

I will email you privately with a dentist recommendation for you. It will involve some travel, but you need to get this done right.

– Dr. Hall

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About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

Dear Dr. Hall,
I had full mouth smile makeover done (veneer crowns) in January 2017, 12 upper teeth and 10 lower teeth. After they put permanent crowns on, I felt sharp pain on teeth #5 and #13 (upper second premolars). The dentist did crown height adjustment 3-5 times, finally the pain went away, but tooth abscesses formed on top of both #5 and #13 teeth within 4-6 weeks. The dentist x-rayed and said the teeth nerves had died, and I need root canals. I was upset and didn’t realize that nerve damage could be a risk involved in veneer crowns. I remembered I asked if there is any risk doing smile makeover during consultation, I was told there is no risk. The X-ray showed that my teeth nerve are fine before the procedure. I am confused and don’t understand what is going on.

The dentist said he didn’t know why, it rarely happened, I am the unlucky one. He referred me to an endodontist to perform the root canal procedure, and the endodontist found more teeth showing no response to cold test, also my gum flared up, swollen and very painful. So far I have had root canals done on 4 teeth (#4, #5, #13, #14), and #12 needs a root canal too, just matter of time. The tooth #3 starts feel strange too. Dr. did agree to pay half of the cost of the 4 root canals, but I am worried it will be an ongoing nightmare. What if the crowned teeth one by one goes bad over the time? I am very frustrated and feel misled. It not only financially cost me, but also add lots of stress on me. Please tell me what i should do and I need some advice. Thanks!
Sincerely,
Jenny from Texas

Jenny,
To answer your question, I first need to lay down some terminology so we’re clear in what we’re talking about. I’m a big fan of clarity in communication, which requires precisely defining what words mean.

Porcelain Veneer Preparation

You’re saying you had “veneer crowns.” But a porcelain veneer is one thing and a porcelain crown is something very different. A porcelain veneer requires very light shaving of the front surfaces of the teeth—sometimes no shaving at all is required. I found this photograph that illustrates a typical porcelain veneer preparation. Maybe half a millimeter of tooth structure has been shaved off, and the porcelain will be bonded over this.

Porcelain Crown Preparation

This second photograph shows a typical porcelain crown preparation for the same two front teeth. Much more tooth structure has been removed.

It appears from your description that what you had done were porcelain crowns, not porcelain veneers. It is very rare that a porcelain veneer preparation on a tooth will end up making it need a root canal treatment. But a crown preparation will go much deeper into the tooth, increasing the risk of a pulp exposure, resulting in an infection of the pulp and the need for a root canal treatment.

A smile makeover, by itself, does not require any aggressive grinding down of the teeth, which is what must have been done in your case. If your teeth had large fillings or decay before getting your makeover, then grinding them down was necessary. If that is the case, it wouldn’t be surprising if some of those teeth ended up needing root canal treatments. Anytime there is a lot of decay or large old fillings, there is a risk of teeth getting infected. But I would call that procedure a full-mouth reconstruction, not a smile makeover.

But if this that you’re calling a smile makeover was just for aesthetic reasons, then your dentist was much more aggressive than he needed to be, and I believe he should be responsible for the cost of the damages he caused. If you weren’t told of any of these risks up front, he is especially vulnerable.

A smile makeover should be done with porcelain veneers whenever possible, to avoid problems like you are having. There is even a trend in recent years for excellent cosmetic dentists to place what are called ultra-thin porcelain veneers, which require even less preparation than is shown in the photograph above. Some even try to do the makeover without preparing the teeth at all. But many dentists who aren’t expert in cosmetic dentistry simply don’t know how to do porcelain veneers very well, and so they resort to full coverage crowns. Porcelain veneers aren’t taught in dental schools—they’re a cosmetic procedure for which a dentist should get post-graduate education.

As far as what you should do now, I don’t know what to tell you. You don’t really have any option, if you want to save these teeth, besides having the root canal treatments done. And it’s curious that your dentist is offering to pay half the cost of the root canal treatments. This seems to indicate that he is feeling some guilt over this. If that’s the case, I would press him to pay the whole thing.

About what to expect long term, it’s hard for me to tell for sure from here. My guess would be that any teeth that end up having problems, you will find out within the first few months and then things will stabilize.

Dr. Hall

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About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

Here is a question from John from New York. It’s hard to follow. Don’t try to understand all of this—I summarize his problem in the first paragraph of my answer.

Dr. Hall,
had full mouth reconstruction, all crowns, one bridge, removable upper partial. No wax up done. First set temps occluded well, still original partial and not great occlusion on left side, as was with original teeth. When lower perms delivered, lost all occlusion, only 5 and 28 touched, dentist did not address issue, when upper perms delivered, occlusion worse as the six lower teeth no longer fit inside the front uppers. I could not chew and side to side was unassisted by proper mechanics. I addressed this after completion and a number of attempts to remedy the occlusion were tried by grinding down the right side, then by modifying the partial. At each step of treatment my bite got progressively worse, and at the end, all attempts to alter the partial also gave progressively worse results. If I were to place implants in 12 and 4, which would allow me to lose the partial, I would have to have 13, 11 and 6 crowns redone as they do not occlude. l have offered to pay at least the lab fees to correct the non occluding crowns, but for some reason the dentist chose to keep trying to fix the issue by modifying the partial, which also got progressively worse and is now very uncomfortable, causes pain on some teeth when chew, and because of adding material to the saddle, has a squeezing rubbery effect when bite down. I have tried to get help from two other very well qualified dentists but neither of them said they saw anything wrong, other than one who did admit that the partial was doing nothing, but did not mention that 13, 11 crowns and 12 on the partial were not occluding and that 5 and 28 were the only teeth touching. I want to fix my bite but between not wanting to pay to have at least three crowns redone and make a new partial, and hope any of the other crowns won’t need to be redone as well, and because of how my confidence has been shaken by what appeared to be the two dentists being more concerned about protecting the dentist who did the work than they were about my health and welfare, I am stuck trying to figure out what my best course would be. I’d appreciate some guidance. Thank you.
John

John,
I am having a hard time following your story, so I am not sure of the details of what happened to you. Here is the gist of what I am getting from you:
You had what you are calling a full mouth reconstruction which implies that every tooth in your mouth was treated, using a combination of crowns, bridges, and a removable upper partial. You say the first set of temps (I assume you’re talking about a temporary partial, temporary crowns and bridges) fit well. But the permanent partial is not occluding well, as well as some of the other dental work. I am having trouble sorting out what occludes and what doesn’t occlude, but regardless, I couldn’t be of much specific help without personally examining you. However I think I can be of some help with this matter of your occlusion.

And then I understand that you are wondering if the other dentists helping you are more concerned about protecting their colleague than helping you. I also know quite a bit about that subject.

Occlusion is a complex subject

On the subject of occlusion—that is a very complicated subject. How the teeth interact with each other, with all their bumps, ridges, and pits, is complicated enough. But then you have this complicated joint, the TMJ, that allows a hinge motion, sliding back and forth and side to side—no other joint in the body does anything close to that—and dealing with it is beyond the capacity of a dentist who has merely graduated from dental school. There are high-powered institutes that are devoted to nothing more than the post-graduate training of dentists in the subject of occlusion and how it affects the TMJ and associated muscles. You need to find a dentist with a higher level of expertise to sort out your problems and fix them. As I said, I don’t know clearly what has happened in your case, but I am strongly suspicious that your dentist has gotten in over his head.

So how do you find a dentist who can sort out your occlusion? Look for a dentist trained at one of these occlusion institutes I mentioned. The two most prestigious are in South Florida. One is the L.D. Pankey Institute, the other is the Peter Dawson Academy. Both of these teach conventional occlusal theory. Another respected institute is the Las Vegas Institute. It teaches a different, functional theory of occlusion that also seems to work well in practice. There are others, such as the Texas Center for Occlusal Studies, but these three are the most popular. A dentist trained at any one of these institutes should be able to help you.

True professionalism

On the other issue, yes, it is very common for dentists to band together and defend each other against the interests of the patient. I get occasional flak from other dentists who tell me that my criticism of some dentists is unprofessional (see the “hate mail” category in this blog). That is their thinking. My thinking is the opposite—that the highest professionalism is serving the patient and calling out mistakes when I see them. That is why I counsel patients seeking second opinions to go outside their local area.

My advice

I see you are in a suburb of Rochester, New York. My advice to you would be to do a search on the term “TMJ dentist” in Rochester, look at the doctor bio of each dentist you find, and select a dentist who is either Pankey or Dawson trained and enjoys working with this complex field of TMJ treatment. And before you make an appointment with the dentist, ask if he or she would be comfortable going to bat for you in getting some type of refund from your family dentist to help defray the cost of fixing what he or she messed up.

And, as you have learned, it might be easiest to select a dentist across town who doesn’t know your dentist.

Dr. Hall

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About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

Dr. Hall,
I just got a new crown on an upper molar, and it does not feel like it meshes with the tooth below it. I think it needs a deeper indentation to accomodate the tooth below. Is there a risk of damaging the tooth in drilling away more of the surface of the crown? My dentist says to give it time to get used to it. It’s been two weeks and still is uncomfortable.
– Criss from New York

Criss,
I smile thinking about your dentist’s response, “Give it time to get used to it.” That’s a classic “I don’t know what to do” response. Now this could be a particularly difficult situation, or this could reveal a lack of knowledge of your dentist.

A new crown or onlay should not be noticeable when you bite or chew. It should be so perfectly comfortable that you don’t even know it’s there. But the occlusion between your upper and lower teeth is very complicated with all the various motions that are involved in chewing, and many dentists are simply not experts in that. There are post-graduate institutes dentists can attend such as the Texas Center for Occlusal Studies, the Pankey Institute, the Las Vegas Institute for Advanced Dental Studies, the Dawson Academy, and others. These institutes train dentists in the science of occlusion–how the upper and lower teeth mesh and are supposed to function together. Many dentists attend these institutes, or will attend other solitary courses where the same principles are taught. But many don’t feel that they need this training, that their basic dental school education was enough, and they go through their careers with a fairly rudimentary understanding of occlusion. Without this training, they may not be qualified to do a full-mouth reconstruction, but they can do single crowns or onlays. They may have some patients who experience what you are experiencing–the teeth don’t feel quite right, but for the most part they get by. Yes, in time, over a period of months, you will probably get used to it, and it may cause no further complications. But an occlusal problem like this can in some cases lead to unnatural stresses on the teeth which can contribute to bone loss around the affected teeth. Or in some cases it can be a precipitating factor to TMJ disorder.

Many dentists will simply adjust a new crown or onlay so that it isn’t high. They will ask you to bite on what it called bite registration paper, and that paper will leave marks where the crown or onlay hits prematurely and then will grind down those places. I’m assuming that your dentist has done that basic step and that this onlay isn’t “high”–you can clench together without discomfort–and what is wrong with your bite is more subtle.

What should you do? The best thing would be to get the tooth adjusted so that it is comfortable. No, that shouldn’t damage your new onlay. Such adjustments are fairly common with new dental work, and there should be plenty of thickness in the new onlay to accommodate any necessary adjustments. But if your dentist doesn’t know what the problem is, then I wouldn’t ask him or her to do that, as they could do more harm than good. But then going to another dentist to have this adjusted could be awkward and would involve extra fees.

Here’s what I would recommend. If you’re generally pretty happy with this dentist, then I would let this go and wait a few months to see if this tooth begins to feel like it fits better into your bite. However, I would be leery about having this dentist do another crown or onlay on one of your back teeth.

If you have other points of dissatisfaction with your dentist, this could be a way to find a dentist whom you feel will better meet your needs. Look for a dentist who has publicized his or her training at one of the institutes I mentioned above, ask for a second opinion on this onlay, and if you’re happy with what they do for you, you’ve found a new regular dentist.

– Dr. Hall

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About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.